Service Authorization: Several service categories increased in the First Quarter 2000. The rate of authorization for Outpatient Mental Health services for the entire SW HealthChoices population increased 38% in the First Quarter, returning to rates similar to the Third and Fourth Quarter 1999 (CCBH and VBH increased 38%). Outpatient Mental Health Services for children increased 21% from the First Quarter 2000 to rates that were also similar to the Fourth Quarter 1999 (CCBH increased 26% and VBH increased 17%).
The rate of authorization for Inpatient Mental Health Services for the entire SW HealthChoices population increased 11% from the Third Quarter 1999 to the First Quarter 2000 (CCBH increased 16% and VBH remained stable).
The rate of authorization for Outpatient Drug and Alcohol services for all SW HealthChoices eligible members increased in three of the last four quarters. The rate increased 20% from the Third Quarter 1999 to the First Quarter 2000 (26% for CCBH and 13% for VBH). Greene and Indiana Counties trended toward a low rate of authorization for Outpatient Drug and Alcohol Services. No other counties met the criteria for a low rate of authorization for Outpatient Drug and Alcohol Services. VBH has added specific questions to the CST survey tool to determine preferences for locality in obtaining Drug and Alcohol treatment. They have recently co-located Drug and Alcohol services with a Federally Qualified Health Center (FQHC) in the county.
No counties met the criteria for a low or high rate of authorization for Children's Behavioral Rehabilitation Services.
The rate of authorization for Intensive Case Management (ICM) services for the all SW HealthChoices members increased 18% from the Third Quarter 1999 to the First Quarter 2000 (CCBH increased 15% and VBH increased 22%). Greene and Beaver Counties trended toward a low rate of authorization for ICM Services.
Service Denials: The percentage of members that were denied service was essentially unchanged in the First Quarter 2000 (1.7%) as compared to the Fourth Quarter of 1999 (1.6%). The distribution of denials was similar to the prior year. Inpatient Mental Health services were the most frequently denied service (9.0%). Inpatient Hospital Detox services were the second most frequently denied service (6%).
Grievances: The percentage of denials grieved dropped for both BH-MCOs. The percentage of denials grieved for CCBH has declined in each of the past five quarters from 54% in the First Quarter 1999 to 18% in the Fourth Quarter 1999 and to 10% in the First Quarter 2000.
The percent of VBH denials that were grieved decreased from 41% in the Fourth Quarter 1999 to 31% in the First Quarter 2000.
Complaints: The average number of complaints per month in the First Quarter 2000 increased to 53 per month, from an average of 37 per month in the Fourth Quarter 1999. This continues a trend of increasing complaints present in each Quarter since the HealthChoices program began. Ninety-one percent of complaints were related to provider service and quality of care.
Each of the BH-MCOs had nearly the same number of complaints. The most common complaints to CCBH were no participation in treatment planning (26% of complaints) and provider billed member (23% of complaints). The most common complaint to VBH was dissatisfied with treatment (11% of complaints).
Adult Involuntary Inpatient Psychiatric Admissions: The rate of adults, for the entire SW HealthChoices population, that were involuntarily admitted increased from 3.3 per 1000 adult members in the Fourth Quarter 1999 to 4.5 per 1000 adults in the First Quarter 2000. Allegheny County (CCBH) had the highest rate of adult involuntary admissions among the 10 counties. The rate increased from 4.9 admissions per 1000 adults in the Fourth Quarter 1999 to 7.4 in the First Quarter 2000. The rate of admissions for the counties managed by VBH remained stable at 2.1 admissions per 1000 adults. Beaver County continued to have the second highest rate of involuntary admissions, 4.7 admissions per 1000 adults. Beaver County conducted a study of 49 individuals involuntarily committed. No conclusions could be drawn. CCBH contract requires authorization for at least the initial 48 hours of any 302 approved by a physician.
30 Day Inpatient Psychiatric Readmission: The percentage of inpatients that were readmitted to an inpatient unit within 30 days of discharge for the entire SW HealthChoices population (all ages) was stable over the past three quarters ranging between 16% and 17%. The percentage of children readmitted within 30 days was also stable at 15% for the entire SW HealthChoices population from the Third Quarter 1999 to the First Quarter 2000. In the First Quarter 2000 both BH-MCOs readmitted 15% of children within 30 days. During the First Quarter 2000 the percentage of adults readmitted was 17%. This rate has been steady for the past three-quarters ranging from 16% to 18%. In the First Quarter 2000, the rate of adult 30-day readmission was 19% for CCBH and 14% for VBH. Forty-three percent (43%) of adults admitted to inpatient in Washington County were readmitted within 30 days. This is the highest percentage of readmissions in any quarter for a county since HealthChoices began. Further trending is recommended. CCBH has not seen identifiable results from the focus study on children. They continue to see high no show rates after discharge. VBH conducted a focus study of readmissions in the third and fourth quarter 1999. Lack of follow-up with the discharge plan and medication management accounted for a majority of readmissions. Approximately 25% of readmission cases did not receive follow-up appointments prior to discharge. VBH implemented telephone follow-up calls to members and providers, addressed the findings in their newsletter and provider forums, and will be monitoring in chart reviews. OMHSAS will be monitoring follow-up appointments after discharge of consumers from an inpatient psychiatric facility with a primary diagnosis of schizophrenia. The study, consisting of a medical record review, will be performed by the OMHSAS contracted external quality review organization, IPRO. Individual facility readmission rates will be examined. Pilot projects for improvement are being considered.
Racial Minority Authorization: Allegheny and Beaver continued to show a difference between the percentage of blacks that were authorized to receive a behavioral health service and the percentage of Blacks that participated in HealthChoices. The differences were similar to those found in the prior three-quarters that were measured and are shown below. CCBH has convened a stakeholder task force on cultural competence. Beaver County has funded the Family Service System Reform project serving locations with high African American populations. They are exploring expansion of services to these locations.
Percentage of Blacks Eligible and Authorized for Services
Quarter 1-00 Quarter 1-00 County Eligible Authorized Allegheny 45.3% 36.0% Beaver 19.9% 15.6%
Clean Claims Paid in 30 Days: The First Quarter 2000 report includes clean claims data from the Fourth Quarter 1999. Allegheny County met the PA standard of 90% claims paid within 30 days during two months in the Fourth Quarter 1999 (October and November). During December 79% of Allegheny claims were paid within 30 days.
Two of the nine counties managed by VBH of PA met the PA standard for clean claims paid in 30 days (Armstrong County during November and December, Indiana County during December) during the Fourth Quarter 1999. All counties failed to meet the standard in at least one month during the Fourth Quarter 1999 and seven counties failed to meet the standard for all three months in the quarter.
VBH has taken action to improve claims processing including: establishment of a PA-specific processing unit, Trafford Center management of look-a-like claims, correction of data fields, and establish PA P.O. Box to identify claims more quickly. Counties report a reduction in provider complaints about payment.
Changes in BH-MCO Policy: OMHSAS finalized the Medical Necessity criteria for Intensive Case Management and Resource Coordination, which will be implemented July 1, 2000 unless alternative criteria are approved by OMHSAS. Training on the new standards is being held for the HealthChoices counties and their provider networks.
OMHSAS will delay the implementation of psychiatric rehabilitation services as an in-plan HealthChoices service until January 1, 2002.
There were no reports of major staffing or policy changes from the counties or their BH-MCOs.
Feedback from Stakeholders: Feedback from Stakeholders was received in four categories: access, quality and appropriateness of services, payment, and MCO functions. Access issues included increased demand for MATP services in Fayette, training to clarify children's payment and coding issues, and exploration of models to improve cultural competence. Advocacy from family members of children diagnosed with autism was reported under Quality and Appropriateness of Services. Lack of timely provider payment by VBH has been reported for three consecutive quarters. Progress on the plan of corrective action is beginning to show results. Fayette is applying to become certified as a Utilization Review Entity for the Department of Health. OMHSAS is conducting Annual Reviews of all southwest counties and Early Warning has now been incorporated into the OMHSAS statewide quality management plan.
Status of Unreported Measures:
Homelessness among Serious and Persistently Mentally Ill: Data is being collected through POMS reporting. Test data will be shared with the counties next quarter. It is expected that reporting of this measure will begin in the third quarter.
Children Placed in Residential Treatment: Test data has been run. The template format is being finalized and will be distributed to the Counties in the second quarter of 2000. It is anticipated that they will produce a report for all of 1999 as well as the first three quarters of 2000 during the third quarter.